Home and community-based services waiver

What it means

Medicaid's institutional coverage is an entitlement: somebody who qualifies clinically and financially is entitled to nursing facility care. Care at home historically was not covered at all, which pushed people into facilities they did not need.

A home and community-based services waiver is the correction. A state asks federal permission to waive the usual rules and spend the same money on care delivered at home or in the community — personal care, adult day services, respite for a family caregiver, home modifications, sometimes assisted living.

The crucial difference from institutional Medicaid is that a waiver is not an entitlement. A state may cap the number of places, and most do, which is why waiting lists of months or years are common. Getting onto the list is a separate act from qualifying, and the list does not join itself.

Financial eligibility for a waiver is sometimes more generous than for ordinary Medicaid, because the comparison is against the cost of a facility. It is worth checking rather than assuming somebody earns too much.

Why it matters

It is the main route by which Medicaid pays for somebody to stay at home, and it is the route families most often do not know exists.

Because places are capped, the date somebody joins the waiting list can matter more than the date they qualify.

When you are likely to meet it

• When paid help at home is needed and private funds will not stretch.
• When a discharge plan proposes a nursing facility and home would be possible with support.
• When a state's aging agency mentions a waiver program by a name of its own.

How this varies by state

Every state runs its own waivers under its own names, with its own services, its own eligibility and its own waiting list. This is one of the least uniform parts of Medicaid.

Related terms

• Activities of daily livingThe everyday self-care tasks — bathing, dressing, eating, using the toilet, moving from a bed to a chair, continence — that care assessments and insurance policies measure.
• Adult day servicesA daytime program providing supervision, activity and often health care outside the home.
• Area Agency on AgingA local agency, part of a national network, that arranges and coordinates services for older adults in its own area.
• Home careNon-medical help at home — bathing, dressing, meals, housekeeping, company. Medicare does not pay for it.
• MedicaidA joint federal and state program that pays for health care, including long-term care, for people with limited income and assets.
• Respite careShort-term care that gives an unpaid family caregiver a break — a few hours, a day, or a stay of some days.
• Skilled nursing facilityA facility providing nursing and rehabilitation care that has to be delivered by licensed clinical staff — not the same thing as a nursing home in the everyday sense.
• Spend-downUsing up income or assets on care until they fall below the limit at which Medicaid will start paying.

Official sources

The authority this page describes, at the agency that publishes it. Sahvelo does not restate a rule from a secondary source.

• Medicaid.gov — home and community-based services (opens in a new tab)

Sahvelo guidance that uses this

• Housing and care transitions